Many physicians office now have generalized check list for first or follow-up appointments. I HIGHLY suggest you fill this one out before your appointment and take it with you. It is far more complete and you really want to “think” about it before your appointment. The doc is far more likely to pay attention to this list than one you fill in in the office which is often scored by his assistant and he doesn’t really see or pay attention to at the time of the appointment following instead a “practice protocol”
Please indicate on a scale of 1 to 10 the severity and frequency of each symptom, with 10 being the most severe and frequent. Use the past two months as a general guide. If you do not have the symptom, leave the space blank. (Thanks to Dr. Berne for providing this list.)
DATE:
____________________Fatigue, worsened by physical exertion or stress
____________________Activity level decreased to less than 50% of pre-illness activity level
____________________Recurrent flu-like illness
____________________Sore throat
____________________Hoarseness
____________________Tender or swollen lymph nodes (glands), especially in neck & underarms
____________________Shortness of breath with little or no exertion
____________________Frequent sighing
____________________Tremor or trembling
____________________Severe nasal allergies (new or worsened)
____________________Cough
____________________Night sweats
____________________Low-grade fevers
____________________Feeling cold often
____________________Feeling hot often
____________________Cold extremities (hands and feet)
____________________Low body temperature (below 97.6)
____________________Low blood pressure (below 110/70)
____________________Heart palpitations
____________________Dryness of eyes and/or mouth
____________________Increased thirst
____________________Symptoms worsened by temperature changes
____________________Symptoms worsened by air travel
____________________Symptoms worsened by stress
PAIN
____________________Headache
____________________Tender points or trigger points
____________________Muscle pain
____________________Muscle twitching
____________________Muscle weakness
____________________Severe weakness of an arm or leg
____________________Full or partial paralysis of an arm or leg
____________________Joint pain
____________________TMJ syndrome
____________________Chest pain
EYES AND VISION
____________________Eye pain
____________________Changes in visual acuity (frequent changes in ability to see well)
____________________Difficulty with accommodation (switching focus from one thing to another)
____________________Blind spots in vision
SENSITIVITIES
____________________Sensitivities to medications (unable to tolerate a “normal” dosage)
____________________Sensitivities to odors (e.g., cleaning products, exhaust fumes, colognes, hair sprays)
____________________Sensitivities to foods
____________________Alcohol intolerance
____________________Alteration of taste, smell, and/or hearing
UROGENITAL
____________________Frequent urination
____________________Painful urination or bladder pain
____________________Prostate pain
____________________impotence
____________________Endometriosis
____________________Worsening of premenstrual syndrome (PMS)
____________________Decreased libido (sex drive)
GASTROINTESTINAL
____________________Stomach ache; abdominal cramps
____________________Nausea
____________________Vomiting
____________________Esophageal reflux (heartburn)
____________________Frequent diarrhea
____________________Frequent constipation
____________________Bloating; intestinal gas
____________________Decreased appetite
____________________Increased appetite
____________________Food cravings
____________________Weight gain ( _ lbs)
____________________Weight loss ( _ lbs)
GENERAL NEURLOLOGICAL
____________________Lightheadedness; feeling”spaced out”
____________________Inability to think clearly (“brain fog”)
____________________seizures
____________________Seizure-like episodes
____________________Syncope (fainting) or blackouts
____________________Sensation that you might faint
____________________Vertigo or dizziness
____________________Numbness or tingling sensations
____________________Tinnitus (ringing in one or both ears)
____________________Photophobia (sensitivity to light)
____________________Noise intolerance
EQUILIBRIUM/PERCEPTION
____________________Feeling spatially disoriented
____________________Dysequilibrium (balance difficulty)
____________________Staggering gait (clumsy walking; bumping into things)
____________________Dropping things frequently
____________________Difficulty judging distances (e.g. when driving; placing objects on surfaces)
____________________“Not quite seeing” what you are looking at
SLEEP
____________________Hypersomnia (excessive sleeping)
____________________Sleep disturbance: unrefreshing or non-restorative sleep
____________________Sleep disturbance: difficulty falling asleep
____________________Sleep disturbance: difficulty staying asleep (frequent awakenings)
____________________Sleep disturbance: vivid or disturbing dreams or nightmares
____________________Altered sleep/wake schedule (alertness/energy best late at night)
COGNITIVE
____________________Difficulty with simple calculations (e.g., balancing checkbook)
____________________Word-finding difficulty
____________________Saying the wrong word
____________________Difficulty expressing ideas in words
____________________Difficulty moving your mouth to speak
____________________Slowed speech
____________________Stuttering; stammering
____________________Impaired ability to concentrate
____________________Easily distracted during a task
____________________Difficulty paying attention
____________________Difficulty following a conversation when background noise is present
____________________Losing your train of thought in the middle of a sentence
____________________Difficulty putting tasks or things in proper sequence
____________________Losing track in the middle of a task (remembering what to do next)
____________________Difficulty with short-term memory
____________________Difficulty with long-term memory
____________________Forgetting how to do routine things
____________________Difficulty understanding what you read
____________________Switching left and right
____________________Transposition (reversal) of numbers, words and/or letters when you speak
____________________Transposition (reversal) of numbers, words and/or letters when you write
____________________Difficulty remembering names of objects
____________________Difficulty remembering names of people
____________________Difficulty recognizing faces
____________________Poor judgment
____________________Difficulty making decision
____________________Difficulty following simple written instructions
____________________Difficulty following complicated written instructions
____________________Difficulty following simple oral (spoken) instructions
____________________Difficulty following complicated oral (spoken) instructions
____________________Difficulty integrating information (putting ideas together to form a complete picture or concept)
____________________Difficulty following directions while driving
____________________Becoming lost in familiar locations when driving
____________________Feeling too disoriented to drive
MOOD/EMOTIONS
____________________Depressed mood
____________________Suicidal thoughts
____________________Suicide attempt(s)
____________________Feeling worthless
____________________Frequent crying
____________________Feeling helpless and/or hopeless
____________________Inability to enjoy previously enjoyed activities
____________________Increased appetite
____________________Decreased appetite
____________________Anxiety or fear with no obvious cause
____________________Panic attacks
____________________Irritability; overreaction
____________________Rage attacks: anger outbursts with little or no cause
____________________Abrupt, unpredictable mood swings
____________________Phobias (irrational fears)
____________________Personality changes
OTHER
____________________Rashes or sores
____________________Eczema or psoriasis
____________________Aphthous ulcers (canker sores)
____________________Hair loss
____________________Mitral valve prolapse
____________________Cancer
____________________Dental problems
____________________Periodontal (gum) disease
© copyright 1999 and 2008 by Katrina H. Berne, Ph.D.,